- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,780.00 / $8,350.90 / $21,413.21
| Facility | | $3,780.00 | $8,350.90 | $21,413.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $6,090.55 / $9,251.04
| Professional | | $3,859.17 | $6,090.55 | $9,251.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,164.52 / $3,798.60
| Facility | | $1,493.06 | $2,164.52 | $3,798.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,456.84 / $3,859.17 / $6,753.55
| Facility | | $1,456.84 | $3,859.17 | $6,753.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,050.00 / $3,983.66
| Professional | | $1,050.00 | $1,050.00 | $3,983.66 |